Letters to the Editor
Multinodular goiter with retrosternal extension causing airway obstruction: Management in intensive care unit and operating room Sir, Airway compromise and difficult intubation may be anticipated in huge thyroid with gross tracheal deviation. Retrosternal extension can present with compression of structures below it and may mimic a medical condition or as emergency respiratory obstruction. Benign goiters affect 5% of the general population in nonendemic areas and 15% in endemic areas, and of these 1-15% of all patients undergoing thyroidectomy have a retrosternal goiter.[1,2] A 58-year-old female, with thyroid swelling presented with sudden onset of dyspnea, noisy breathing, and cough with expectoration for 5 days. She was provisionally diagnosed and treated for chronic obstructive pulmonary diseases. She had expiratory wheeze with respiratory distress, bilateral crepitations, rhonchi, with saturation of 85 with oxygen by the mask of 5 L/min, pulse rate of 150 beats/min. She required immediate intubation and respiratory support, Intubated with injection propofol
Figure 1: Lateral view X-ray showing compression of trachea
and injection suxamethonium without difficulty. The lobes of the thyroid gland were diffusely palpable and nodular. Lower pole of thyroid swelling was not palpable. Investigations showed hematocrit 27; white blood cells of 17.700/mm3, thyroid function tests-free T3 0.59 ng/ml, free T4 2.13 mcg/ml, thyroid stimulating hormone 1.25 IU/ml. Lateral view of neck X-ray showed compression of the trachea [Figure 1] and anteroposteior view showed deviation of the trachea to left. Fiberoptic flexible bronchoscope passed through the endotracheal tube (ETT) showed edema and congestion of luminal wall, side-to-side narrowing and intraluminal bulge at the level of thyroid. On computed tomography scan severely narrowed trachea from C6 to D2 with narrowest part at D2 measuring 6 mm and extension of left thyroid gland retrosternally just above the arch of aorta [Figure 2]. She was planned for elective thyroid surgery, after obtaining informed consent, injection glycopyrollate as premedication, induced with propofol, maintained with fentanyl, oxygen, nitrous oxide, isoflurane. ETT was changed to reinforced tube threaded over bougie, during this process patient was breathing spontaneously and had inspiratory stridor as we were exchanging the tube. Intra operative period was uneventful and thyroid gland extending up to arch of aorta. Muscle relaxation maintained with vecuronium and vitals monitored. Post procedure she returned to intensive care for observation for 5 days, flexible intubating fiberoptic scope was introduced into the trachea through ETT, tracheal rings were inspected after withdrawal of ETT up to cricoids cartilage. The integrity
Figure 2: Computed tomography showing thyroid gland just above on the arch of aorta 543
Indian Journal of Critical Care Medicine August 2014 Vol 18 Issue 8
of the cartilages checked by mechanical compression of tracheal rings by the surgeon and observing through the fiber optic scope for the recoil to the original shape. Extubation done confirming there was no collapse of lumen, no stridor or respiratory distress. Upper airway obstruction due to thyroid gland has been reported up to 31% and difficulty in intubation has been reported 11%.[3,4] Central airway obstruction produces symptoms of dyspnea, stridor, or obstructive pneumonia and is often misdiagnosed as asthma. Meticulous planning for managing difficult airway and perioperative care in planned extubation after confirming the absence of airway compromise is of prime importance. Difficult airway algorithms and experience of the anesthesiologist plays a major role in management and outcome of the procedure. The early identification of all probable outcomes and prompt mobilization of resources allowed a favorable outcome in this case.
Acknowledgment We acknowledge our colleague and ENT-ONCO surgeon Prof. S. M. Azeem Mohiyuddin for his dedication and patient care throughout the management of this case.
Ravi Madhusudhana, B. R. Krishna Kumar, N. Suresh Kumar, R. B. Rakesh, K. R. Archana, B. G. Harish
Department of Anaesthesiology, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India
Correspondence: Dr. N. Suresh Kumar, Department of Anaesthesiology, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India. E-mail: [email protected]
References 1. 2. 3. 4.
Abraham D, Singh N, Lang B, Chan WF, Lo CY. Benign nodular goitre presenting as acute airway obstruction. ANZ J Surg 2007;77:364-7. Cohen JP. Substernal goiters and sternotomy. Laryngoscope 2009;119:683-8. Hedayati N, McHenry CR. The clinical presentation and operative management of nodular and diffuse substernal thyroid disease. Am Surg 2002;68:245-51. Amathieu R, Smail N, Catineau J, Poloujadoff MP, Samii K, Adnet F. Difficult intubation in thyroid surgery: Myth or reality? Anesth Analg 2006;103:965-8. Access this article online Quick Response Code: Website: www.ijccm.org
DOI: 10.4103/0972-5229.138163
544
Management of snake bite victims in a Tertiary Care Intensive Care Unit in North India Sir, We read with interest the clinical profile and manifestations of snakebite patients from a Medical College in Rural Area of Himachal Pradesh.[1] We would like to share our experience and emphasize on the different management regimes being followed world over. Twenty-five cases of snake bite were admitted in our Intensive Care Unit (ICU) from October 2012 to September 2013; three-fourth of them presented from June 2013 to September 2013. Patients with fang marks and swelling, cellulitis, bleeding, and blisters formation at the local site were included; any patient with suspicion of snake bite but no direct evidence was excluded. Mean age was 31.16 years (range: 13-70 years) and male to female ratio was 18:4. All patients presented with neuroparalytic features and reported of snake bite in the night during sleep. The mean duration of the ICU stay was 4.32 days (range: 3-13 days). The mean dose of equine polyvalent antisnake venom (ASV) administered was 48.63 vials (range: 40–60 vials). No patient had any adverse reactions to the antivenom. No other complication, namely acute renal failure, acute respiratory distress syndrome, cortical venous thrombosis or disseminated intravascular coagulation was reported during hospitalization. They were mechanically ventilated for a mean period of 3.18 days. D o s e o f A S V u s e d b y R a i n a e t a l . [1] w a s 292.69 ml ± 196.27 ml (range: 50-950 ml) which is 6 times higher than that reported in our series. They have thus reported allergic reactions in 7% of patients. Test doses have not been shown to have predictive value in predicting anaphylactic reaction or late serum sickness and are not recommended neutralizing power of antivenoms varies from batch to batch and this may be partially responsible for the difference. National Snakebite Management Protocol prepared by Ministry of Health and Family Welfare, India clearly defines the dose and routes of administration of ASV.[2] The recommended initial dose of ASV is 8-10 vials administered via intravenous route over a period of 1 h. Repeat doses for hemotoxic species
Copyright of Indian Journal of Critical Care Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Multinodular goiter with retrosternal extension causing airway obstruction: Management in intensive care unit and operating room Sir, Airway compromise and difficult intubation may be anticipated in huge thyroid with gross tracheal deviation. Retrosternal extension can present with compression of structures below it and may mimic a medical condition or as emergency respiratory obstruction. Benign goiters affect 5% of the general population in nonendemic areas and 15% in endemic areas, and of these 1-15% of all patients undergoing thyroidectomy have a retrosternal goiter.[1,2] A 58-year-old female, with thyroid swelling presented with sudden onset of dyspnea, noisy breathing, and cough with expectoration for 5 days. She was provisionally diagnosed and treated for chronic obstructive pulmonary diseases. She had expiratory wheeze with respiratory distress, bilateral crepitations, rhonchi, with saturation of 85 with oxygen by the mask of 5 L/min, pulse rate of 150 beats/min. She required immediate intubation and respiratory support, Intubated with injection propofol
Figure 1: Lateral view X-ray showing compression of trachea
and injection suxamethonium without difficulty. The lobes of the thyroid gland were diffusely palpable and nodular. Lower pole of thyroid swelling was not palpable. Investigations showed hematocrit 27; white blood cells of 17.700/mm3, thyroid function tests-free T3 0.59 ng/ml, free T4 2.13 mcg/ml, thyroid stimulating hormone 1.25 IU/ml. Lateral view of neck X-ray showed compression of the trachea [Figure 1] and anteroposteior view showed deviation of the trachea to left. Fiberoptic flexible bronchoscope passed through the endotracheal tube (ETT) showed edema and congestion of luminal wall, side-to-side narrowing and intraluminal bulge at the level of thyroid. On computed tomography scan severely narrowed trachea from C6 to D2 with narrowest part at D2 measuring 6 mm and extension of left thyroid gland retrosternally just above the arch of aorta [Figure 2]. She was planned for elective thyroid surgery, after obtaining informed consent, injection glycopyrollate as premedication, induced with propofol, maintained with fentanyl, oxygen, nitrous oxide, isoflurane. ETT was changed to reinforced tube threaded over bougie, during this process patient was breathing spontaneously and had inspiratory stridor as we were exchanging the tube. Intra operative period was uneventful and thyroid gland extending up to arch of aorta. Muscle relaxation maintained with vecuronium and vitals monitored. Post procedure she returned to intensive care for observation for 5 days, flexible intubating fiberoptic scope was introduced into the trachea through ETT, tracheal rings were inspected after withdrawal of ETT up to cricoids cartilage. The integrity
Figure 2: Computed tomography showing thyroid gland just above on the arch of aorta 543
Indian Journal of Critical Care Medicine August 2014 Vol 18 Issue 8
of the cartilages checked by mechanical compression of tracheal rings by the surgeon and observing through the fiber optic scope for the recoil to the original shape. Extubation done confirming there was no collapse of lumen, no stridor or respiratory distress. Upper airway obstruction due to thyroid gland has been reported up to 31% and difficulty in intubation has been reported 11%.[3,4] Central airway obstruction produces symptoms of dyspnea, stridor, or obstructive pneumonia and is often misdiagnosed as asthma. Meticulous planning for managing difficult airway and perioperative care in planned extubation after confirming the absence of airway compromise is of prime importance. Difficult airway algorithms and experience of the anesthesiologist plays a major role in management and outcome of the procedure. The early identification of all probable outcomes and prompt mobilization of resources allowed a favorable outcome in this case.
Acknowledgment We acknowledge our colleague and ENT-ONCO surgeon Prof. S. M. Azeem Mohiyuddin for his dedication and patient care throughout the management of this case.
Ravi Madhusudhana, B. R. Krishna Kumar, N. Suresh Kumar, R. B. Rakesh, K. R. Archana, B. G. Harish
Department of Anaesthesiology, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India
Correspondence: Dr. N. Suresh Kumar, Department of Anaesthesiology, Sri Devaraj Urs Medical College, Tamaka, Kolar, Karnataka, India. E-mail: [email protected]
References 1. 2. 3. 4.
Abraham D, Singh N, Lang B, Chan WF, Lo CY. Benign nodular goitre presenting as acute airway obstruction. ANZ J Surg 2007;77:364-7. Cohen JP. Substernal goiters and sternotomy. Laryngoscope 2009;119:683-8. Hedayati N, McHenry CR. The clinical presentation and operative management of nodular and diffuse substernal thyroid disease. Am Surg 2002;68:245-51. Amathieu R, Smail N, Catineau J, Poloujadoff MP, Samii K, Adnet F. Difficult intubation in thyroid surgery: Myth or reality? Anesth Analg 2006;103:965-8. Access this article online Quick Response Code: Website: www.ijccm.org
DOI: 10.4103/0972-5229.138163
544
Management of snake bite victims in a Tertiary Care Intensive Care Unit in North India Sir, We read with interest the clinical profile and manifestations of snakebite patients from a Medical College in Rural Area of Himachal Pradesh.[1] We would like to share our experience and emphasize on the different management regimes being followed world over. Twenty-five cases of snake bite were admitted in our Intensive Care Unit (ICU) from October 2012 to September 2013; three-fourth of them presented from June 2013 to September 2013. Patients with fang marks and swelling, cellulitis, bleeding, and blisters formation at the local site were included; any patient with suspicion of snake bite but no direct evidence was excluded. Mean age was 31.16 years (range: 13-70 years) and male to female ratio was 18:4. All patients presented with neuroparalytic features and reported of snake bite in the night during sleep. The mean duration of the ICU stay was 4.32 days (range: 3-13 days). The mean dose of equine polyvalent antisnake venom (ASV) administered was 48.63 vials (range: 40–60 vials). No patient had any adverse reactions to the antivenom. No other complication, namely acute renal failure, acute respiratory distress syndrome, cortical venous thrombosis or disseminated intravascular coagulation was reported during hospitalization. They were mechanically ventilated for a mean period of 3.18 days. D o s e o f A S V u s e d b y R a i n a e t a l . [1] w a s 292.69 ml ± 196.27 ml (range: 50-950 ml) which is 6 times higher than that reported in our series. They have thus reported allergic reactions in 7% of patients. Test doses have not been shown to have predictive value in predicting anaphylactic reaction or late serum sickness and are not recommended neutralizing power of antivenoms varies from batch to batch and this may be partially responsible for the difference. National Snakebite Management Protocol prepared by Ministry of Health and Family Welfare, India clearly defines the dose and routes of administration of ASV.[2] The recommended initial dose of ASV is 8-10 vials administered via intravenous route over a period of 1 h. Repeat doses for hemotoxic species
Copyright of Indian Journal of Critical Care Medicine is the property of Medknow Publications & Media Pvt. Ltd. and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
